The latest news, views and opportunities from EWM Towers
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Employers positively seek out members of the Expedition & Wilderness Medicine Community so please mention ‘EWM’ when enquiring...
DDRC Healthcare is a charity providing hyperbaric oxygen therapy (HBO), training and research in Diving and Hyperbaric Medicine and associated fields. In conjunction with Plymouth Hospitals NHS Trust, we are looking to appoint two junior doctors for 6 month posts – one doctor to commence February 2015 and the other August 2015.
The post will be an average of 6 sessions per week at DDRC and 4 sessions per week in the Emergency Department. We are looking for Doctors with a minimum of 2 years experience post qualification. You must have full registration with the GMC or be eligible to become fully registered.
Derriford Hospital is adjacent to DDRC and is the largest teaching hospital in the southwest with a busy Emergency Department. DDRC provides HBO for elective and emergency patients for conditions including Decompression Illness, tissue damage secondary to radiotherapy and diabetic ulcers.
Training will be provided in Diving and Hyperbaric Medicine and successful candidates will be encouraged and funded to enrol in the Postgraduate Certificate in Remote Healthcare run by the Plymouth University Peninsula Schools of Medicine and Dentistry.
There is no on call commitment for the diving aspect of this post however individuals will be encouraged to be involved in the management of diving accidents. The ED sessions may include some night shifts.
For application form and further information see Employment section www.ddrc.org
To discuss the job or to arrange a visit – please contact Dr Christine Penny – [email protected] or 01752 209999
Closing date: 18.08.2014 (08.00) interview date: 05.09.2014
Courses and Conferences of Interest
DDRC Healthcare is a charity providing hyperbaric oxygen therapy (HBO), training and research in Diving and Hyperbaric Medicine and associated fields. In conjunction with Plymouth Hospitals NHS Trust, we are looking to appoint two junior doctors for 6 month posts – one doctor to commence February 2015 and the other August 2015.
The post will be an average of 6 sessions per week at DDRC and 4 sessions per week in the Emergency Department. We are looking for Doctors with a minimum of 2 years experience post qualification. You must have full registration with the GMC or be eligible to become fully registered.
Derriford Hospital is adjacent to DDRC and is the largest teaching hospital in the southwest with a busy Emergency Department. DDRC provides HBO for elective and emergency patients for conditions including Decompression Illness, tissue damage secondary to radiotherapy and diabetic ulcers.
Training will be provided in Diving and Hyperbaric Medicine and successful candidates will be encouraged and funded to enrol in the Postgraduate Certificate in Remote Healthcare run by the Plymouth University Peninsula Schools of Medicine and Dentistry.
There is no on call commitment for the diving aspect of this post however individuals will be encouraged to be involved in the management of diving accidents. The ED sessions may include some night shifts.
For application form and further information see Employment section www.ddrc.org
To discuss the job or to arrange a visit – please contact Dr Christine Penny – [email protected] or 01752 209999
Closing date: 18.08.2014 (08.00) interview date: 05.09.2014
Courses and Conferences of Interest
Contact KEN DUNN at Connecting Communities Worldwide for more info:
E: kdunn”AT”ccwltd.org
T: 01709 717 111
M: 0752 852 9766
Expedition & Wilderness Medicine is the leading provider of training for medics working in remote and austere environments.
Contact KEN DUNN at Connecting Communities Worldwide for more info:
E: kdunn”AT”ccwltd.org
T: 01709 717 111
M: 0752 852 9766
Expedition & Wilderness Medicine is the leading provider of training for medics working in remote and austere environments.
If you are available, 14th – 23rd March and can provide medical support to a group of mixed nationalities, we’d love to hear from you.
Please send your CV, location and brief note expressing your interest to: admin AT expeditionmedicine.co.uk by Sunday 9th March, 2014.
Read more about the trek here
Not many things you can say that change your life! Attending the Wild Medicine course was one of those events.
Amazing set of people and a fantastic opportunity to learn about conservation and desert medicine.
The kind of odd things we learnt…
– Take blood from a cheetah,
– Learn about (and touch – optional) many poisonous snakes,
– Sleep in a desert, walk 14km through a dry river canyon,
– What are the problem animals with Rabies? (A: Kudu),
– How can carnivores live outside conservation areas & not get killed by farmers &
villagers?
– How to build a vineyard in a desert … what?!..And the thing that changed our lives? Meet the Bushmen and see their need for healthcare! My wife and I are volunteering at Naankuse to run the Bushmen medical services. The real thing we learned? There are many people out there that can benefit from our skills …
Oh and by the way Namibia is amazing you get to see loads … but you can also get a 4×4 and do a week or so trip before the course.
Not many things you can say that change your life! Attending the Wild Medicine course was one of those events.
Amazing set of people and a fantastic opportunity to learn about conservation and desert medicine.
The kind of odd things we learnt…
– Take blood from a cheetah,
– Learn about (and touch – optional) many poisonous snakes,
– Sleep in a desert, walk 14km through a dry river canyon,
– What are the problem animals with Rabies? (A: Kudu),
– How can carnivores live outside conservation areas & not get killed by farmers &
villagers?
– How to build a vineyard in a desert … what?!..And the thing that changed our lives? Meet the Bushmen and see their need for healthcare! My wife and I are volunteering at Naankuse to run the Bushmen medical services. The real thing we learned? There are many people out there that can benefit from our skills …
Oh and by the way Namibia is amazing you get to see loads … but you can also get a 4×4 and do a week or so trip before the course.
Expedition Medicine’s UK Course Welcomes their University Liaison
With the sunshine out and the rasping sounds of the Search and Rescue Teams over the two-way radios out on the Cumbria hills – you would have been easily mistaken in thinking you were in the middle of a real emergency. In fact, it was the final Search and Rescue exercise (with CASEVAC) of a fantastic 4 day Expedition Medicine Course in Keswick in Cumbria.
As the University Liaison for Expedition Medicine, it was the first course that I attended as a new member of the ‘EM faculty’ – and what a fantastic experience it was. Not only did I get to absorb the electric atmosphere of the 60+ delegates there alongside the seasoned expedition medics leading the course but it gave me ample opportunity to see how such courses can align themselves with my role as University Liaison and to stimulate a few more ideas.
International Extreme Medicine EXPO- Expedition & Wilderness | Tactical | Disaster Medicine
‘Taking Medicine To The Extremes’
A major new International ‘World Extreme Medicine conference and EXPO’ series with the first inaugural event in London April 2012 followed by Salt Lake City in September 2012 with the very best speakers from around the world, leading figures from the world of expedition and wilderness travel, displays from focused industry leaders and also awards. All CME accredited on a modular basis to allow you select just a day or to attend the entire medical expo.
Over the last ten years the care of casualties in a remote environment has come a long way. This has been driven by conflict, the apparent exponential rise in natural disasters and our capacity to respond on an international scale and not least by the evolving interest in the field of expedition and wilderness medicine. The conference concept was generated out of a desire to amalgamate the associated specialties in this field and to share the skills and knowledge we have acquired. It will run over 4 days and involve some of the major specialists in their field of remote and austure medicine.
Developed specifically with medical professionals in mind the International ‘World Extreme Medicine EXPO’ will also be of interest to other medical specialists and students for which there will be a discounted rate.
To pre-register your interest for ‘Extreme Medicine’ email us here.
International Extreme Medicine EXPO- Expedition & Wilderness | Tactical | Disaster Medicine
‘Taking Medicine To The Extremes’
A major new International ‘World Extreme Medicine conference and EXPO’ series with the first inaugural event in London April 2012 followed by Salt Lake City in September 2012 with the very best speakers from around the world, leading figures from the world of expedition and wilderness travel, displays from focused industry leaders and also awards. All CME accredited on a modular basis to allow you select just a day or to attend the entire medical expo.
Over the last ten years the care of casualties in a remote environment has come a long way. This has been driven by conflict, the apparent exponential rise in natural disasters and our capacity to respond on an international scale and not least by the evolving interest in the field of expedition and wilderness medicine. The conference concept was generated out of a desire to amalgamate the associated specialties in this field and to share the skills and knowledge we have acquired. It will run over 4 days and involve some of the major specialists in their field of remote and austure medicine.
Developed specifically with medical professionals in mind the International ‘World Extreme Medicine EXPO’ will also be of interest to other medical specialists and students for which there will be a discounted rate.
To pre-register your interest for ‘Extreme Medicine’ email us here.
The treatment of cholera in an active malaria zone is a difficult matter. This is especially true with lessons being learned in Haiti and their recent cholera outbreak. I am specifically referring to the combination of Chloroquine (antimalarial) and the antibiotic class Macrolides (used in treatment of cholera). A post that I made back in 2009 has new recent relevance and I wanted to repost that here:
Azithromycin, Chloroquine and Arrythmias:
Travel medicine frequently uses medicines that are taken under special circumstances and for short periods of time, like a trip. Many travelers carry an antidiarrheal antibiotic on their trip and a common choice is azithromycin. This can potentially be a problem when they are also traveling in a malaria area and using chloroquine for prevention. Two very commonly used medicines chloroquine (antimalarial) and azithromycin(macrolide antibiotic used for respiratory infections and diarrhea) both have wonderful safety profiles, individually. However when taken together, there is discussion of the chance of a heart arrhythmia, specifically prolonging the QT interval. In fact, my software I use for prescribing cites this as a combination to avoid.
There are several important articles that can be used to look at this problem and evaluate the risks. One very good paper looks at medications that prolong this QT interval:
These authors list azithromycin as a “very improbable” medication, although other macrolides are listed as higher risk. Chloroquine is listed as an “Unknown” medication, with respect to prolongation of QT interval. This article was based on expert opinions.
This study looked directly at this problem, in animal models. Their research showed no increase in arrhythmia risk.
A wonderful article that is actually helping to look at using this drug combination to treat resistant forms of malaria. More about this combination and treating malaria here. Their study did show an increase in the QT interval in both groups of those who received chloroquine alone and those who received the combination of chloroquine and azithromycin. This QT interval increase was maximum on day number three and returned to baseline by the end of the study.
Most of the information I am finding looks reassuring for safely using this combination, in healthy individuals. Those with a history of arrhythmia should use this combination with caution and discuss this problem with their doctor, before they take these two medicines within a close amount of time.
Contributer: Dr Erik McLaughlin | www.adventuredoc.net
Pre-hospital Expedition Medicine Series
Dr Amy Hughes, Medical Director of Expedition Medicine and Pre-Hospital Emergency Medicine Registrar and HEMS paramedic Dave Marshall, both part of the Kent Helicopter Emergency Medical Team, continue their series examining pre-hospital expedition trauma care and associated kit.
In the second article in the series, Dave Marshall gives an overview of managing pelvic fractures pre-hospitally and in an expedition environment, and introduces the use of the pelvic splint.
Edited by Dr Amy Hughes.
Pre hospital and Expedition management of pelvic trauma and use of the pelvic splint
Expeditions have become more and more adventurous over the past years, both in destination and the participants involved. As a result, the frequency and pattern of injury is changing and the demand on the medical team thus increased. Having a broad knowledge of fracture management, including mechanism of injury, clinical findings, reduction techniques and splinting is essential. Although one of the most enjoyable challenges of being a medic on an expedition team is improvisation regarding kit used to manage various ailments and injuries, practice and competence in the use of non-improvised kit such as the Pelvic Sam Splint is essential.
Mechanism of Injury
Pelvic fractures often result in extensive disruption of the bony structures and associated ligaments of the pelvis and are potentially life-threatening injuries. The fractures associated with the greatest morbidity and mortality involve significant forces such as motor vehicle crashes, motorcyclist crash, pedestrian versus car, falls from height and crush injuries. Early suspicion, identification and management of a pelvic fracture at the prehospital stage is essential to reduce the risk of death as a result of hypovolaemia, (1). It is especially important to be able to identify, treat and minimize risk of further damage when in a remote area miles from the nearest medical facility.
Understanding the mechanism of injury is vital in being able to predict the potential for significant injury to the pelvis and its underlying structures, even in the absence of clinical signs. It is, therefore, essential that time is taken to evaluate the mechanisms involved in any accident resulting from significant force or where there is pain or injury to the spine, abdomen, pelvis or femurs.
In motor vehicle accidents – a not uncommon event on expeditions – learning how to ‘read’ the wreckage to help identify possible pelvic injury, in conjunction with clinical suspicion, can significantly aid diagnoses.
The intrusion into the passenger and drivers door is likely to result in massive lateral injury to the pelvis.
The intrusion into fuel tank shows the imprint of the riders pelvis. This would often result in significant fracture to the pelvis – often multiple, often ‘’open book’’ pelvis.
Anatomical structure of the pelvis
The pelvic ring is often likened to a polo mint in that it is almost impossible to have a significant break in one place and not another. The most common area to be damaged in trauma is the pubic rami, acetabulum and the sacroiliac joint. There is extensive vasculature through and around the pelvic ring, most notably the iliac vessels. For imagery see > http://visualsunlimited.photoshelter.com/image/I0000kUOn3NJHcZU.
The greatest risk of a pelvic fracture is catastrophic haemorrhage and gentle handling of the patient in the initial and subsequent stages could literally be the difference between life and death. Whole blood clotting time is approximately 10 minutes, (depending on the environment). Expedition medics should be familiar with the ‘first clot best clot’ theory. In other words, a patient sustaining a traumatic injury resulting in haemorrhage will begin to form a clot using their own clotting factors. If this clot is disrupted they could easily bleed to death. A full fluid resuscitation will not be practical in the field as most expeditions carry a maximum of 2 litres of crystaloid. However it should be noted that overloading the patient with fluid can be equally harmful, and small boluses should be given to maintain a central pulse and cerebral perfusion. This is known as permissive hypotension and will be discussed in more detail in a future article. Disruption of this first clot in the prehospital setting could be fatal, and without access to blood and clotting agents the patient may die. Trauma will result in the patient becoming acidotic, hypothermic, and coagulopathic. (3)
This coagulopathy cannot be easily reversed pre-hospitally, each factor contributes to the decline in the others. (see above diagram). Any disruption to the first clot will have devastating consequences. Ultimately, the patient requires definitive haemorrhage control, (surgery, angiography and embolisation), and replacement of blood and clotting agents.
The glass pelvis: Think of the pelvis as being made of very fragile glass, and you can see the clot in the form of a cartoon jelly inside. The jelly is very delicate and unless movement is gentle and kept to a minimum, it will ‘wobble’ to the point of destruction very easily. The same applies to the blood clot! Early recognition of the potential for a pelvic injury, gentle handling and prompt stabilisation is vital to improve the outcome of a patient injured on an expedition.
Clinical Features of a pelvic injury:
As we have already discussed, a patient with a suspected pelvic fracture must be handled very carefully. Whether in a medical facility or the most extreme expedition environment, the same principles apply to prevent worsening the injury and preserving the clot.
Log rolling the patient should be avoided at all costs!
The medical kit available on expeditions will be minimal. Stretchers may have to be improvised and transportation limited. However, all medical kits should have some sort of pelvic binder which should be applied carefully and correctly at the earliest opportunity,
Application of the pelvic SAM splint.
The casualty will inevitably have to be placed in the supine position, to evacuate them on whichever device is available. This can be achieved by a coordinated team approach utilising other members of the expedition.
One person should be at the head end of the patient maintaining in manual inline immobilisation, (MILS), and they will give clear commands to the team when moving the casualty, (“ready, brace, roll”). A pelvic binder such as the one shown can be applied using a minimal 10-15% roll, (enough to get a bum cheek off the ground!)
Once in position the device can be tightened just enough to maintain anatomical alignment. Do not over tighten as this could cause significant further damage!
Log rolling patients.
Whilst sometimes useful in a controlled hospital environment following appropriate imaging, should be avoided in the pre hospital field. In simple risk versus benefit terms it could have catastrophic consequences. By using the hands available and correctly briefing the team about the amount of movement required (one cheek off!), it should be possible to optimise the care of the casualty prior to evacuating them to definitive care.
Improvised methods of pelvic splinting on expeditions
Much of the challenge of expedition medicine is improvisation. The medical kit you take out with you may not have SAM splints in them. Providing a support can be placed across the greater trochanter, then any sort of material could be used – for example clothing, a sheet, or a canvass of some kind.
Fluids
The approach to fluid management in trauma has changed. Two litres of fluid is not necessarily required for management of pelvic injury. Titrate fluid according to the presence of pulses or cerebration (alertness). The presence of a radial pulse, and even in certain circumstances (without associated head injury) presence of a femoral pulse signifies the blood pressure is sufficient to perfuse the necessary organs and promote clot preservation. Further details of permissive hypotension will follow in another article.
Analgesia
Essential – this depends on what is available. Intravenous opiates or a fentanyl lolly is ideal for analgesia, after the use of paracetamol or a NSAID.
Other injuries
Pelvic injuries are often present in conjunction with other significant injuries – spinal, femur, urological or abdominal as examples. Whether or not other injuries have been excluded, spinal precautions are essential in conjunction with good management of the pelvis.
References
Feedback on our recent Polar Medicine training course in Norway has clearly affected some of the course delegates by creating a need for ‘biggles-speak’…
PapaFoxtrot calling Red Leaders AlphaHotel, AlphaCharlie, DeltaBravo, Bravo and Delta
Congrats on recent Operation Polar Bear
Wizard week
No prangs
Best ever
Location stunning
Bunks and chow excellent
Red Leaders all SPLENDID
Hope all returned to base safely
Please pass on to all members of Polar Bear as don’t have call signs
Do you read me ?
Over
Dr Amy Hughes medical career has been far from ordinary and she talks about how she has ended up as medical lead at EWM.
Dr Hughes co-leads with Dr Luanne Freer our CME accredited Mountain Medicine course on the Everest Base Camp trail in Nepal.
A team of four university friends from the South of England are attempting a record-breaking expedition across the Indian Ocean this summer. They are being supported on land by Expedition Medicine’s University Liaison, Dr Nick Knight who is their research coordinator, trainer and nutritionist.
The team is planning to row the 3100 miles from Australia to Mauritius in less than 68 days, 19 hours and 40 minutes – the fastest ever crossing time for a 4s boat.
Starting out in Geraldton, Western Australia the crossing will finish on the island of Mauritius and with only eleven boats having so far successfully completed the crossing, the adventure will be tough. The expedition will see the four man crew suffer extreme fatigue, mental stress and intense isolation. They risk crippling sores and the countless dangers involved in crossing a great Ocean in a small open craft. The adventurers will have minimal help from winds and currents, so will need to row in 2 hour shifts for 24 hours a day for almost ten weeks to complete their mission.